WHILE 700 NEW CLINICS HAVE IMPROVED ACCESS TO TREATMENT, SERVICE HAS BEEN WEAKENED IN PLACES BY A SHRINKING WORKFORCE
Science and Health Editor
SA's health service has declined in many areas while having to serve an increasing proportion of the country's population over the past 10 years.
According to the latest SA Health Review, conducted by the Health Systems Trust on behalf of the health department, there have been significant interventions since the advent of democracy such as the building of more than 700 clinics and the provision of free primary health care.
But the health service has declined in many areas, and inequalities between provinces loom large, says the annual publication, first published in 1995.
District level spending on primary health care ranges from R389 a person a year in richer districts to just R42 in poorer areas. As a result many districts are unable to provide adequate primary health care, which has an estimated cost of R220 a head.
The explanation for this shortfall is that although government spending on the public health sector is projected to have increased by R8,7bn in real terms over 10 years much of this funding has been absorbed by HIV/AIDS, medical inflation and relatively higher salaries.
Current real spending a person is struggling to match levels seen in the mid-to-late 1990s, as the number of people using public-health facilities is estimated to have grown by 7-million since 1996.
The number of patients using private-sector health care, largely with medical scheme membership, has remained static during this period. As the population grows, a greater proportion relies on the state to provide for medical needs.
The review highlights the paradoxical situation where real spending has increased, but the sector has 19 000 fewer employees.
Although personnel budgets increased by about R3bn over a 10-year period, average wage costs increased about 28% in real terms (to an average wage of R98 153 last year).
One of the biggest drains on the public health system is HIV/AIDS.
The review estimates that the epidemic costs about R6bn a year, and it says that the sector is not being compensated adequately for this.
"Reviewers make the point that despite the gains we have made in many areas, the impact of the HIV/AIDS epidemic has reversed many of the early health status gains," says health department spokesman Sibane Mngadi.
"We need to better understand this impact and the extent to which our interventions are reversing this trend the 2003 SA District Health Survey, which should be available later this year, should be able to assist us to understand this."
Perhaps the most damning chapter in the review is one on tuberculosis (TB). It highlights how even when the health department has the right programmes in place it can still fail to treat an easily cured disease.
"Improvements in the overall management of the national (TB) control programme have not translated into effective control of the TB epidemic the incidence of TB continues to grow, whilst cure rates remain unacceptably low and treatment interruption rates unacceptably high," says the review.
The World Health Organisation (WHO) estimated that in 2002 SA had 243 000 TB cases, the seventh highest case load in the world. It also has the highest HIV and TB coincidence rate in the world, with 60% of TB patients coinfected with HIV.
Although SA now has DOTS an internationally agreed treatment strategy designed to ensure patients take their medicines properly in 182 out of 183 districts only 54% of patients with TB were documented to have successfully completed their treatments, a far cry from the WHO's 85% target. Western Cape achieved the highest cure rate, and KwaZuluNatal performed worst.
The review says the TB problem is due largely to a lack of funds and inadequate human resources. In urban areas health workers and "treatment supporters" supervised by health workers are providing DOTS effectively, but in rural areas treatment supporters are poorly supervised.
There are also problems in maintaining patient records, and the data being collected is not being used to improve service delivery.
Data collection is a major shortcoming in the public health system, says the review, making it difficult for managers to monitor progress.
Although there has been some improvement, and the health department has initiated monitoring programmes, there are still major gaps no one knows how many disabled people there are in SA, for example.
The review also highlights government's glaring failure to manage its human resources and effectively combat the exodus of skilled staff to the private sector or abroad.
An estimated 600 South Africantrained doctors are registered to practise in New Zealand, and 10% of Canada's hospital-based physicians and 6% of the UK's health workforce are South African.
The review emphasises that the shortage of doctors and nurses is felt most acutely in poor rural areas, and adds its voice to the growing chorus calling on government to develop a strategy to combat the paucity of skilled health-care workers.
As a final note of warning, it cautions that the shortage of skilled health workers threatens to undermine government's ambitious promise to provide free AIDS drugs.
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